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FEMERGe4CY <br /> RGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> HAS STATE OFFICE OF EMERGENCY SERVICES FORLOCALAGENCY: ONLY <br /> REPORT BEEN FILED 7 <br /> NO yes ❑ NO I HEREBY CEROFYTHATI HAVEDISTRIBTHINFORMATTON ACCORDING TOTHE OISIREWTIQN SHOWN CN THE INSTRUCTION SHEET ON THE BACK PAGE OfTH45 FORMCASE adywl Gid a 9 v -, ` ol�ly <br /> NAME OF INDIVIDUAL FILING REPORT DATE <br /> PHONE SIGNATURE.. <br /> w REPRES NG ❑ OwNERIOPERATOR ❑ REGIONAL BOARD COMPANY Oq AGENCY NAME <br /> OLOCAL AGENCY a OTHEfl S �^ <br /> ¢ ADDRESS ,./ `��n 70u vin Gs (e e (4/� <br /> /Yf /V . Skn-%CJ �vr.. vT, S/e c,rG{ / C�4 gSyp / �UB Zov�j� <br /> w NAME <br /> CONTACT PERSON nv <br /> PHONE <br /> i J G n C UNKNOWN <br /> y ADDRESS 4'�-�— I ) yG A/- 77 qv <br /> c / IGS IDRAis ,e o/ S.Lv �k "7,n <br /> sneer <br /> FACILITY NAME(IF APPLICABLE) � gATe 'nn <br /> / I OPERATOR PHONE <br /> �y <br /> ADDRESS L f /, (� <br /> ( VL-Y-77YD <br /> A,3'^n/ C4 <br /> m CROSS STREET clrr ��. <br /> F LOCAL AGENCY AGENCY NAME <br /> CONTACT PERSON <br /> w PHONE <br /> wi ) <br /> w REGIONAL BDaRD <br /> y a I PHONE <br /> QUANTITY LOST(GALL, <br /> `° fA C UNKNOWN <br /> m <br /> N <br /> W DATE DISCOVERED NOW DISCOVERED / ❑ UNKNOWN [' , <br /> I /� �/ ❑ F7lfOPY CONTRCI. ❑ SU85URFACE MONITORING ❑ NUISANCE CONDITIONS <br /> 4 /u� / o� l�rl ' r ❑ TANK TEST TANK REMOVAL OTHER <br /> m DATE DISCHARGE BEGAN ❑ - ^" <br /> a METHOD USED TO STOP DISCHARGE ALL THAT APPLTT <br /> C <br /> MI pl UNKNOWN ❑REMOVE CONTENTS OSE TANKB REMOVE REPAIR PIPING <br /> O HAS DIS RGE BEEN STOPPED t ❑ CLOSE TANK 8 FILL W PLACE CHANGE PROCEDURE <br /> REPAIR TANK ❑ a <br /> ❑ YES ❑ NO IFYES.DATE uI �. d vl y ❑REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGE <br /> Uw I CAUSE(SI <br /> j a F7 TANK LEAK UNKNOWN C OVERFILL ❑ flUPTUflE1FA1WRE ❑ SPILL <br /> m O ❑ PIPING LEAK ❑ 0714ER <br /> ❑ <br /> CHECKO ONLY CORROSION ED UNKNOWN ❑ OTHER <br /> w w <br /> U r <br /> UNDETERMINED ❑ SOIL ONLYGROUNDWATER <br /> ❑ ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AF'eCTEO) <br /> CHECK ONE ONLY <br /> ¢� C NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED <br /> Q POLLUTION CNAiUCTERf(ATION <br /> < ❑ LEAK BEING CONFIRMED ❑ PRELIMINA <br /> tiH Ry SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> ❑ <br /> REMEDIATION PLAN E:3 CASE <br /> CHECK APPROPRIATE ACTION(S) CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ <br /> CLEANUP UNDERWAY <br /> faawea Qr.ul ❑ EXCAVATES DISPOSE(ED) ❑ REMOVE FREE PRODUCT(M ❑ ENHANCED BIO DEGRADATION <br /> CAP S (In <br /> 0 0 ❑ ITE(CD) EXCAVATE a TREAT El (El ❑ PUMP a TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RST <br /> ymo <br /> ❑ CONTAINMENT BARRIER(CS) NO ACTION REQUIRED <br /> ¢ ❑ MAI ❑ TREATMENT AT IdCOKUP(HU) ❑ VENTSOIL(VS) <br /> ❑ <br /> VACUUM EXTRACT(VE) r7 OTHER(OT) <br /> fry / <br /> ,. <br /> ow / prrr<ri+grn Iw T4s KLc7<G/.�p 4�c C/c`A`�C ti� p-f C /t .,,/.�-�' GT G.S rl�KlNr/ �c-C� /L <br /> ❑ Y ✓ ic_� <br /> nsc ml✓roR <br />